Provider Demographics
NPI:1932195450
Name:WILSON, MARK DENNIS (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:DENNIS
Last Name:WILSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 W EXCHANGE ST
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49456-2024
Mailing Address - Country:US
Mailing Address - Phone:616-846-0620
Mailing Address - Fax:616-844-6079
Practice Address - Street 1:314 W SAVIDGE ST
Practice Address - Street 2:
Practice Address - City:SPRING LAKE
Practice Address - State:MI
Practice Address - Zip Code:49456-1607
Practice Address - Country:US
Practice Address - Phone:616-844-7000
Practice Address - Fax:616-844-7444
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003705152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI204829649OtherTAX ID
MI900F111210OtherBCBS OF MICHIGAN
MI(94)4830440Medicaid
MI383628290OtherTAX ID
MI900F210170OtherBCBS OF MICHIGAN
MI900E310260OtherBCBS OF MICHIGAN
MI383521610OtherTAX ID
MI201249427OtherTAX ID
MI900F111210OtherBCBS OF MICHIGAN
MI900E310260OtherBCBS OF MICHIGAN
MI5472600010Medicare NSC
MIN96840009Medicare PIN
MIDC1560Medicare PIN
MI383628290OtherTAX ID
MIN96840009Medicare ID - Type Unspecified
MI5189400001Medicare NSC
ON88020Medicare PIN
MI0P13290Medicare PIN
MI383521610OtherTAX ID
MIP21400008Medicare ID - Type Unspecified
MI(94)4830440Medicaid
MI5375940002Medicare PIN